Forced vs Consensual Opioid Tapering: Which do you like the most?

[drusso]

it is so important to reiterate this point.


and that was the point of the CDC guidelines at the start - for primary care to carefully consider when to start and how much to prescribe. all that has gotten lost in the noise of high dose patients complaining they lost their supply.

The taper KOL's promoted this.

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[deleted875186]

The most insane thing to me is the notion that a doctor should be pushed to continue a dangerous medication without evidence of benefit, just because the risk of stopping it abruptly can also be harmful. No other field of medicine has any ridiculous scenario like this.

 

[MitchLevi]

The most insane thing to me is the notion that a doctor should be pushed to continue a dangerous medication without evidence of benefit, just because the risk of stopping it abruptly can also be harmful. No other field of medicine has any ridiculous scenario like this.

Specifically the risks of stopping it are what?

Self-limited withdrawal is safe unless your pt has a complicated cardiac PMH. Not crazy to think withdrawal could precipitate an arrhythmia or something.

Suicide.

 

[SeniorWrangler]

Yeah it’s funny how the fun part of the job is also the part that pays well and the unpleasant part of the job doesn’t pay much and gets lots of patient complaints.

 

[DrMDAware]

This is why I’m happy to be working in an ortho group compared to a pain group. My eyebrows do raise at the patients they sometime send for an epidural because a shoulder or hip surgery didn’t work well, but overall I spend my time with patients that want to get better and are open to procedures.

I don’t have anyone on chronic standard opioids, just a few on butrans (because I decided it was needed, not another doc or the patient demanding meds)

My front desks tells all prospective patients that I don’t offer chronic medication management, and only 1-2 med seekers slip through each year.

I don’t enjoy opioid hostage negotiations, some docs do. I can do them and practiced in a group of pain docs for a couple years, but I’d rather not do chronic opioids because “it doesn’t add joy to my life” -Marie Kondo-

It’s great that others offer meds as some patients definitely need them. However, I don’t want people threatening me or my staff, I don’t want to deal with these issues and other opioid hassles, and I make a lot more money focusing on PT and procedures for patients.

I agree with you.

However, playing devils advocate, what about a day full of Level 4s with reasonable patients on stable doses? Would that not be financially lucrative with the new RVUs ? Or are you saying the juice ain’t worth the squeeze?

 

[bedrock]

I agree with you.

However, playing devils advocate, what about a day full of Level 4s with reasonable patients on stable doses? Would that not be financially lucrative with the new RVUs ? Or are you saying the juice ain’t worth the squeeze?

I've never run the numbers. The biggest issue in this potential scenario you mentioned is a pain practice "full of reasonable patients on stable doses"

In my experience with outpatient chronic medication management you might have a majority of reasonable patients on stable doses, but you'll still have several hostile patients each day, drug seeking, bargaining, threatening, etc, and this detracts from my quality of life

It is a much of a mental health decision as much as it is one of financial health.

Again, I applaud those doing this important work like Ductape, but this is not how I choose to structure my practice.

 

[oreosandsake]

If PCPs just stopped writing opioids for these patients, and stopped passing the buck to the next pain clinic, we would be in a better situation.

Even when I stop writing opioids for a patient of mine that has an inconsistent urine, says they’re not helping much anymore, or otherwise violates the opioid consent, the PCP automatically picks up prescribing and sends a referral to another pain clinic. Makes me think they don’t even read my note.

PCP Referral reason: low back pain

Referral notes: was established for 4 years but now wants new pain management second opinion.

Pain notes: patient uds positive for everything besides prescribed medicine.
States they got the everything bagel and that’s where the cocaine meth and soma came from. Taper and referral to addiction med counseled offered suboxone etc
Was being rx norco 10 bid for past 10 months

Patient at eval: my last doc was a jerk! Oh I’m out of oxy 30 qid. Can you prescribe for me today? Xanax too

 

[lobelsteve]

Not screening patients is a danger to your career.
Not screening patients is a danger to your mental health.
Not screening patients is just plain stupid.
Your boss says not to do it: you need a different job. Grow a pair if that is the case.

 

[bedrock]

PCP Referral reason: low back pain

Referral notes: was established for 4 years but now wants new pain management second opinion.

Pain notes: patient uds positive for everything besides prescribed medicine.
States they got the everything bagel and that’s where the cocaine meth and soma came from. Taper and referral to addiction med counseled offered suboxone etc
Was being rx norco 10 bid for past 10 months

Patient at eval: my last doc was a jerk! Oh I’m out of oxy 30 qid. Can you prescribe for me today? Xanax too

Standard LA Pain consult.
Don’t miss those….